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HELPS PV

PHOTOVOLTAIC REBATE APPLICATION FORM


OWNER INFORMATION
Customer Name Electric Account Number:
Street Address: Phone #:
City, State & Zip Code: Email:
Social Security Number (if receiving rebate)

SYSTEM REPRESENTATIVE INFORMATION (RESPONSIBLE FOR REPORTING TO HELPS PV (HOMEOWNER or INSTALLER)
System Representative : Phone #:
Company (if applicable): Email:
Street Address: City, State & Zip:

CONTRACTOR AND INSTALLER INFORMATION IF MORE THAN ONE CONTRACTOR LIST THEM ALL
Contractor/Vendor Company: Date Contract Signed:
Contractor/Vendor Contact: Contractor License #:
Taxpayer Indentification Number (if receiving rebate)
Street Address Phone:
City, State & Zip: Email:

AMOUNT OF REBATE REQUESTED
$
Applicants Signature: Date:







In addition to this completed rebate application form, with original signatures, the
following supporting materials must be submitted at the time of application:
_____ Applicable technical worksheet(s) including production estimates
_____ Site plan showing orientation and location of critical components
_____ One line electrical diagram showing all major components and interconnections
_____ Budget and cost estimates, and/or copies of quotations from vendors
_____ Manufactures specification sheets for all major components including warranty information
_____ Copy of contract or proposal between the customer/facility owner and the installer/vendor
----------------------------------------------------------------------------------------------------------------------
I certify that the statements made in this application, including all attachments and exhibits,
are true and correct to the best of my knowledge.


Applicant (Printed Name and Address of Applicant): Signature of Applicant:
Name of Authorized Representative (Printed): Title of Authorized Representative:
Daytime Phone #: Date of Application Submittal:
Anticipated Project Start Date: Anticipated Project Completion Date:



Mail to:
HELPS PV
Attention: Program Manager
327 Moody Street
Ludlow, MA 01056

Or, email to: HELPS-PV@ipswichutilities.org













PV Technical Worksheet
System Owner/Applicant: Project/System name:
PV Manufacturer: Quantity of PV Units:
PV Model#:
STC=standard test conditions

Rated Output (per unit) at STC:
PV Panel Rate Efficiency:
watts output/m) (1000 watts input / m) =% efficiency

Total Array Surface Area (m):
Inverter Manufacturer: Quantity of Inverters:
Inverter Model: Max Rated Inverter Output (per unit):
Inverter Location: Location of AC Disconnect Switch:
Storage System (if any): Storage Capacity (if any):
Maximum Rated System Output (kW):
(provide back-up fromPVWatts or other source)

Estimated Annual Production (kWh):
Array Type
: ___Fixed
___Single axis azimuth tracking
___Dual axis tracking
___Inclination adjusted seasonally___Other (describe):
Array Location: ___Rooftop ___ Pole or ground mount
Azimuth:
(must be between 90 and 270; 180 =true south)
Inclination or Tilt:
(flat on roof =0 ; vertical on wall =90)
Other Notes on PV System: Average #of Hours/Day Array in Shaded:

PC Incentive Calculation Table
Base Incentive: $0.80 per Watt
Additional Incentive: Made in USA Components (both PV Panels and Inverter required for eligibility) $0.05 per Watt. Maximum rebate =
$4,250
Base Incentive X Rated Output (Watts)
Made in USA Components Adder x Rated Output (Watts)
TOTAL REBATE REQUESTED: